South Georgia Transitional Living Center Intake/Referral Form

South Georgia Transitional Living Center Intake/Referral Form

Complete this intake/referral form using the packet requirements. Include all applicant, program, health, history, consent, privacy, release, and conditional screening information.
Applicant Information
Full Name

First NameMiddle NameLast Name
Preferred Name
Date of Birth

MonthDayYear
Date
Age
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Current Address or Last Known Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Services Requested
Service Group
Requested services

Other
Other requested service details
Current Living Situation
Current living situation

Other
If other, please specify
Emergency Contact
Emergency Contact Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Family/Children
Do you have children?
Children details
Employment & Income
Employment Status
Employer
Work Schedule
Monthly Income
Source of Income
Education & Independent Living
Highest Education Level Completed
Able to Live Independently?
Self-Sufficiency Skills

Other
Health, Disabilities, and Medications
Disabilities or accommodations needed
Medical conditions
Medications
Justice System/Foster Care Background
Have you ever been involved with the justice system?
Are you currently on probation or parole?
Foster care history or related details
Motivation & Goals
Reason for Seeking Services
Goals While in Program
Consent to Services
Client Name

First NameMiddle NameLast Name
Client Signature
Date

MonthDayYear
Date
Staff Signature
Staff Date

MonthDayYear
Date
Confidentiality & Privacy Agreement
Client Signature
Date

MonthDayYear
Date
Staff Signature
Staff Date

MonthDayYear
Date
Release of Information
Name / Agency
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Information to Share
Duration of Release
Release Authorization Signature and Date
Reentry Screening
Eligibility for Reentry Services
Current Legal Status

Other
Program Fit / Reentry Needs
Applicant Acknowledgment
Staff Screening Notes / Assessment
Veteran Screening
Veteran status
Housing and VA services needed

Other
Employment and support needs

Other
Acknowledgment
Staff use only: veteran screening notes / assessment
Should be Empty:

South Georgia Transitional Living Center Intake/Referral Form

Applicant Information

Services Requested

Current Living Situation

Emergency Contact

Family/Children

Employment & Income

Education & Independent Living

Health, Disabilities, and Medications

Justice System/Foster Care Background

Motivation & Goals

Consent to Services

Confidentiality & Privacy Agreement

Release of Information

Reentry Screening

Veteran Screening